- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $6,907.00
| Facility | | $6,907.00 | $6,907.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.04 / $1,153.85 / $1,153.85
| Professional | | $1,082.04 | $1,153.85 | $1,153.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.50 / $1,087.28 / $1,851.81
| Professional | | $874.50 | $1,087.28 | $1,851.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.00 / $1,320.00 / $1,320.00
| Facility | | $1,320.00 | $1,320.00 | $1,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.48 / $1,062.94 / $2,704.87
| Professional | | $788.48 | $1,062.94 | $2,704.87 |